Persius/hicric huggingface dataset:
Appeal type: Step Therapy
Decision: Upheld

Diagnosis: Psoriasis, Psoriatic Arthritis

Treatment: Taltz

The insurer denied coverage for Taltz.

The denial is upheld.


The patient has a diagnosis of psoriasis and psoriatic arthritis. The patient has failed therapy with methotrexate as well as topical agents. The requested medication is Taltz.

Based on the medical documentation, Taltz is not medically necessary based on step protocol.  There is no documentation of a contraindication nor a Taltz-specific indication which would reasonably favor the use of Taltz over multiple formulary alternatives, including Enbrel, Humira, Stelara, Skyrizi, and Tremfya.  Multiple formulary alternatives are available, which are considered first line therapies with excellent efficacy for the treatment of psoriasis and psoriatic arthritis.  The list of available formulary alternatives is reasonable and poses no barrier to the patient's clinical improvement. No specific contraindications to these formulary alternatives is noted in the documentation. As such, there is no documentation provided which would warrant, as medically necessary, the use of Taltz over formulary alternatives as a preferred standard of care. The use of Taltz would not be medically necessary over approved formulary alternatives in a patient who has not tried any prior biologic and with no contraindication to available reasonable alternatives. The denial is upheld based on the documentation provided.  

The insurer's required/formulary prescription drugs (Stelara, Tremfya, Cimzia, Enbrel, Skyrizi, or a preferred adalimumab product) are not contraindicated or likely to cause an adverse reaction or physical or mental harm to the patient.

The insurer's required/formulary prescription drugs (Stelara, Tremfya, Cimzia, Enbrel, Skyrizi, or a preferred adalimumab product) are not expected to be ineffective based on the patient's known clinical history, condition and prescription drug regimen.

The patient has not tried the insurer's required/formulary prescription drugs (Stelara, Tremfya, Cimzia, Enbrel, Skyrizi, or a preferred adalimumab product) under their current or previous health insurance coverage, or another prescription drug in the same pharmacologic class or with the same mechanism of action.

The patient is stable on a prescription drug selected by their health care professional for their medical condition.

It cannot be said that the insurer's required/formulary prescription drugs (Stelara, Tremfya, Cimzia, Enbrel, Skyrizi, or a preferred adalimumab product) are not in the patient's best interest because they will likely cause a significant barrier to the patient's plan of care, will likely worsen a comorbid condition, or will likely decrease the patient's ability to achieve or maintain reasonable functional ability in performing daily activities.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a Class I malocclusion, severe maxillary crowding and severe mandibular crowding, moderate overjet and moderate overbite in a mixed dentition of 12 primary teeth remaining. At issue is the medical necessity of braces.

Using the Handicapping Labio-Lingual Deviation (HLD) index, cases need to have permanent dentition or are at least the age of 13 years old to be scored. The patient in this case still has 12 primary teeth and the patient is still under the age of 13, so an HLD score cannot be determined. Thus, the malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Considering the presence of 12 primary teeth and age being less than 13 years old, according to the standard of care, the requested health service/treatment of braces is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Genitourinary 
Inpatient hospital

Diagnosis: decreased kidney function
Treatment: inpatient stay
The insurer denied inpatient stay
The health plan's determination is overturned. 

This case involves a man with nonalcoholic cirrhosis, who was admitted to the hospital for concerns of decreased kidney function and lightheadedness. The patient was reportedly admitted the previous week and treated for spontaneous bacterial peritonitis. On admission, the patient denied fevers, chills, or abdominal pain. He was non-compliant with lactulose. He complained of black stools but is supplemented with oral iron. He also endorsed a 5-pound weight gain. Vital signs on admission showed a temperature of 36.9 C, respirations of 16, blood pressure of 135/58, and heart rate of 94. The cardiopulmonary exam was unremarkable. The abdomen is described as soft, nontender, and non-distended. 

The inpatient hospital admission was medically necessary. The patient has advanced cirrhosis and a recent history of spontaneous bacterial peritonitis and presented to the hospital with weight gain and acute kidney injury. Dehydration and severe persistent, with concern for hepatorenal syndrome and increased creatinine by more than 0.3, qualify for inpatient hospitalization. The patient's baseline creatinine is 1.4 and has increased to 2.24. Diuretic therapy was discontinued, and the patient required colloid infusion to restore fluid balance. Treatment of fluid status in end-stage liver disease patients is clinically challenging. Fluid shifts must be monitored very closely, with frequent clinical and laboratory reassessments. The acuity of illness is often quite severe. This patient has evidence of advanced liver disease, with synthetic dysfunction as evidenced by elevated international normalized ratio (INR). The calculated Model for End-Stage Liver Disease (MELD) score is 20, which is another qualifying factor for inpatient hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colitis
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 with right-sided abdominal pain, nausea, vomiting, diarrhea, lightheadedness, and chills. She was only tolerating water as oral intake. 
A computed tomography scan of the abdomen and pelvis showed moderate severe right and transverse colitis, no free air or collection, and no evidence of appendicitis. She was treated with intravenous fluids, metronidazole, levofloxacin, and ceftriaxone. She was made nil per os.
A gastroenterology consultation noted colitis with suspected infectious etiology, recommended awaiting stool study results, and consider colonoscopy if symptoms persist and stool studies are negative.  She was treated with azithromycin, and ceftriaxone and metronidazole were discontinued. She was started on a pureed diet with thin liquids. A pulmonology consultation noted dysphagia, mild bibasilar fibrosis, likely chronic thromboembolic pulmonary hypertension, mild pulmonary hypertension, and multifactorial dyspnea; the recommendation was to avoid tadalafil for now, and no further interventions or testing before endoscopy. Her abdominal pain was resolved, her bowel movements had become soft, and she had no hematochezia, melena, nausea, or vomiting; she was requesting to eat but noted dysphagia. Lab results showed an unremarkable complete blood count and basic metabolic panel. A chest x-ray showed a mild oblong opacity at the left lung base, slightly more pronounced in the prior radiograph, which may relate to atelectasis and/or infiltrate; the lungs were otherwise without consolidation, or large-volume pleural effusion. An esophagogram was normal. She was discharged. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care was not medically necessary.  The patient presented with abdominal pain, nausea, vomiting, and diarrhea, with finding of Salmonella on stool pathogen testing.  She was appropriately maintained on antibiotic therapy with advancement of diet as tolerated [1-4].  However, there was no hemodynamic instability (such as hypotension), severe gastrointestinal bleeding, severe diarrhea, or other severe complications of infectious colitis.  No other cause for colitis, such as Crohn's disease or Ulcerative Colitis, was documented [5,6].  She had hypokalemia, with successful repletion on the same day, and no complications of hypokalemia [7]. The care provided, including monitoring, labs, Gastroenterology consultation, and empiric antibiotic therapy, could have been provided without the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: braces, retainer and monthly visits
The insurer denied braces, retainer and monthly visits.
The determination is overturned.

The patient is a female with a Class II Division 1 malocclusion with maxillary and mandibular spacing. She has a 9-millimeter (mm) overjet and 2 mm overbite. She has lip incompetence at rest. She is treatment planned for 30-36 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces, retainer and monthly visits.

This patient, like fifteen percent of the population, exhibits an Angle's Class II bite.1 Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. In her particular case, teeth 7-10 are very proclined. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. (2) Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. There is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjet, which this patient has. (3) For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: abdominal pain/vomiting.
treatment: inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

This is the case of a female who presented to the emergency department (ED) after 4 days of vomiting with fever and abdominal pain. The review of symptoms (ROS) was negative for diarrhea, sore throat, congestion, cough, and dysuria.
The emergency department (ED) vitals were T (temperature) 37.4C, heart rate (HR) 140, respiratory rate (RR) 24, blood pressure (BP) 108/74, and O2 (oxygen) saturation 100%. The exam was notable for diffuse abdominal tenderness R>L (right greater than left) with guarding. Labs showed white blood cell count (WBC)=17.2 and normal electrolytes. An abdominal ultrasound did not visualize the appendix. A computed tomography (CT) scan was negative for appendicitis but did show fatty liver infiltration, some decreased attenuation in the right kidney, and mild bladder wall thickening. A diagnosis of pyelonephritis was made, and the patient was admitted to the hospital for intravenous (IV) antibiotics and supportive measures.

The inpatient hospital admission was medically necessary for this patient.
This child presented with fever, vomiting, abdominal/ costovertebral angle (CVA) tenderness, and clinical findings consistent with pyelonephritis. Urinalysis (UA) showed nitrates and WBCs (white blood cells), and the computed tomography (CT) abdomen/pelvis showed abnormalities of the kidney and bladder consistent with a diagnosis of pyelonephritis. Given the need for intravenous (IV) antibiotic treatment and the patient's inability to tolerate oral treatment, inpatient hospitalization was necessary for stabilization and treatment to minimize renal injury.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vertigo

Treatment: Inpatient admission

The insurer denied inpatient hospital admission and it should be reversed.

The denial is reversed. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. In their Final Adverse Determination letter, they stated that the patient was diagnosed with vertigo. The patient was concerned that she was having a stroke. No clinical documentation from the inpatient stay was received. The requested admission is denied based on Excellus Corporate Medical Policy for Medically Necessary Services (11.01.15). 

The patient is appealing. In an appeal letter, she stated that she presented to the emergency room (ER) with complaints of severe dizziness. Diagnostic testing ruled out a stroke. An Otolaryngology consultation was done, and ear problems were detected. The patient was discharged. The patient was not able to open her eyes without seeing spinning. Per the appealer, the inpatient admission was medically necessary. 

This is a case of a patient who presented to the emergency room (ER) with severe vertigo, imbalance, hearing loss, and vomiting.  The patient was unstable and could not get out of bed or open their eyes without vertigo.  The patient was admitted for work up.  The patient had a computed tomography (CT) scan, magnetic resonance imaging (MRI), and cardiac work up.  All of the above were negative for stroke or cardiovascular disease.  The patient was unable to get out of bed and was not safe for ambulation.  The patient was seen and treated by Physical Therapy. The patient was also seen by Ear, Nose, and Throat (ENT) and neurology.  The patient was treated for possible labyrinthitis versus Meniere's disease.  On hospital day 6, the patient was deemed safe enough to ambulate and was discharged home.

This patient was not safe to be discharged home.  The patient required a physical therapy assessment for safe ambulation and recommendations for discharge to home or rehabilitation facility.

The patient had severe vertigo and could not get out of bed safely.  The patient required a full work up for stroke and cardiovascular disease.  Finally, the patient required assessment by physical therapy and recommendation for safe discharge to home or an assisted care facility.

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 the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: DM2 (diabetes mellitus type 2), hypertension, anxiety disorder, Parkinson's disease
Treatment: Increase Personal Care Aide (PCA) Services for A Total Amount of 168 Hours Per Week
The insurer denied Increase Personal Care Aide (PCA) Services for A Total Amount of 168 Hours Per Week.
The denial is overturned.

The patient is an adult male with history of frequent hospitalizations. An Increase in Personal Care Aide (PCA) Services for A Total Amount of 168 Hours Per Week is being requested.

The requested Increase Personal Care Aide (PCA) Services for A Total Amount of 168 Hours Per Week is medically necessary.

The request for Increase in Personal Care Aide (PCA) Services for a Total Amount of 168 Hours Per Week meets the medical necessity criteria per current literature and standard of care for this specific clinical situation. Therefore, the increase in personal care aide to 168 hours/week is medically necessary. Per the appeal letter and assessment system evaluation reviewed, this patient has many ailments, including DM2 (diabetes mellitus type 2), hypertension, anxiety disorder, Parkinson's disease with serious deteriorations and frequent hospitalizations. The patient is unable to care for himself and needs assistance with all ADLs (activities of daily living). The patient is currently unable to use his hands and feet, and he is therefore unable to utilize the DME (durable medical equipment) available. The patient has wounds on his back, and according to his physician, he needs to be repositioned constantly. The patient's spouse is elderly, has her own ailments, and is unable to care for him. The patient has cognitive impairment due to Parkinson's, needs assistance with cooking, cleaning, shopping, showering, dressing, and ambulating, as he is unable to clean, do laundry, wash dishes, cleaning the floor, and fix furniture. The patient requires significant weight-bearing assistance from the caregiver to dress lower body, and for personal hygiene. Caregivers hold the patient's arm to feed due to involuntary movement and weakness. The patient requires assistance with taking on/off of shoes, socks, pants and diapers. The patient has frequent urinary incontinence and wears pull ups. Based upon the above information, Increase Personal Care Aide (PCA) Services for A Total Amount of 168 Hours Per Week is medically necessary.
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. 

This is a female patient diagnosed with Vertebrogenic Low Back Pain.
Letters of appeal submitted by the provider noted that the patient has a history of low back pain that began over 6 months ago. It was reported that she had multiple treatments including activity modification, acupuncture, chiropractic, heat, ice, home exercises, massage therapy, medial branch blocks, medication management, physical therapy, radiofrequency ablation, transcutaneous electrical nerve stimulation (TENS) unit, epidural steroid injection and trigger point injections. Medication included Lyrica and meloxicam. Pain ranges from 4-5/10 and is impacting activities of daily living. The provider stated that the patient had an magnetic resonance imaging (MRI) performed on 10/14/22 showing Modic changes at disc spaces L (lumbar)4 - L5 and L5 - S (sacral) 1. The provider believes that this is the source of the patient's chronic back pain.

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. The provider feels that the patient's pain is coming from Modic changes seen on magnetic resonance imaging (MRI) and the patient was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). This procedure is currently not standard of care as 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.
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 female with complaints of chronic low back pain. Prior treatments have included activity modification, acupuncture, chiropractic, as well as multiple injections. Pain significantly impacts activities of daily living (ADL). Pain ranges from 4-5 out of 10. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic changes at disc spaces L (lumbar)4-L5 and L5-S (sacral)1.

The proposed Nerve Treatment in the Spine: 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.
This procedure is not recommended at the current time. 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.
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. 

This is a female who has chronic back pain with radiating pain into lateral aspect of the lower extremities, left greater right. She describes her pain as aching and sharp. Pain level is 4 out of 10 (4/10). Her pain improved with rest and massage and increased with standing. Her pain started many years ago, but gradually worsened. She has constant numbness in her left foot and tingling in her lower extremities. Her prior treatments include physical therapy (PT), chiropractic manipulation, massage therapy, acupuncture, transcutaneous electrical nerve stimulation (TENS), and medial branch nerve radiofrequency ablation (RFA). 

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 Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient has low back pain with radiating pain and tingling in BLEs (bilateral lower extremities). The magnetic resonance imaging (MRI) reports documented multilevel disc bugles with foraminal stenosis. The provider recommended sacroiliac injection in addition to the Intracept procedure. Truumees's study supported the efficacy of Intracept procedure for vertebrogenic pain. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded. Given this clinical scenario and current studies, the proposed procedure is unlikely to be more beneficial than any standard treatment or treatments for the insured's condition.