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

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

The patient is a male with a Class I malocclusion, moderate spacing of the upper and lower arches and anterior crossbite of teeth number (#)7-#10. He is treatment planned for 30-36 months of orthodontics to correct his malocclusion. At issue is the medical necessity of braces, monthly visits, retainer.
The patient has significant maxillary anterior spacing with #7-#10 in crossbite. These teeth have a high risk for restorative problems in the future due to their 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: Upheld

Diagnosis: Anemia. 
Treatment: Inpatient hospital admission. 
The insurer denied the inpatient hospital admission. 
The denial is upheld. 

The patient is an adult female who presented with shortness of breath and uterine bleeding. The patient was noted to be anemic, and she had a blood transfusion. The patient's exam was unremarkable, and her vital signs were stable. The patient's lab tests were otherwise normal. The patient left against medical advice the next day. 

The inpatient hospital admission was not medically necessary. 

The patient presented with anemia and had a blood transfusion. The rest of the patient's labs, vital signs, and exam were normal. The patient did not have any medical conditions that required inpatient level of care. Inpatient level of care in this setting is not supported by peer-reviewed data, it is not standard of care, and it is not supported by professional organizations. Therefore, the inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Memory problems
Treatment: Magnetic Resonance Imaging (MRI)
The insurer denied Magnetic Resonance Imaging (MRI).
The determination is overturned.

The patient is a female who is seeking approval for magnetic resonance imaging (MRI) of the brain for memory problems. The patient has a history of hypertension, diabetes with neuopathy, anxiety, depression, dyslipidemia, chronic obstructive pulmonary disease (COPD), and Barrett's. Per an office visit note, she had multiple episodes of syncope. She had a negative event monitor. At issue is the medical necessity of an MRI.
Yes. The patient is seeking approval for magnetic resonance imaging of the brain for memory problems.With the new findings of confusions and disorientation, magnetic resonance imaging (MRI) brain is a reasonable study to order and undergo.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a medical history of a recent sleeve gastrectomy and hypertension. She presented to the emergency department with epigastric pain radiating to the back and chest, and nausea. The physical examination was notable for a soft, nondistended abdomen with right upper quadrant and epigastric tenderness. A computed tomography scan of the abdomen and pelvis showed no acute findings. An ultrasound of the right upper quadrant showed lack of cholelithiasis, and right pleural effusion. She was treated with intravenous fluids, pantoprazole, and famotidine. A bariatric surgery consultation recommended no acute bariatric surgical intervention. She had resolution of pain and return of appetite. She was discharged with a plan for primary care and bariatric surgery follow-up. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care is not medically necessary and the care provided could have been provided at a lower level of care. In this case, the patient presented with abdominal pain and elevated lipase consistent with acute pancreatitis [1-3]. Her pancreatitis was uncomplicated, and there were no complications such as pancreatic necrosis, pseudocyst, or abscess [4-6]. No procedural interventions such as endoscopic ultrasound were necessary during the hospital stay. She was appropriately treated with conservative therapy, and her symptoms improved [7-9]. She had elevated liver enzymes, but there was no acute liver failure, choledocholithiasis, or other concerns [10]. The interventions performed, including labs, monitoring, imaging, and Bariatric Surgery consultation, could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vitiligo
Treatment: Laser Treatment for Inflammatory Skin Disease 
The insurer denied Laser Treatment for Inflammatory Skin Disease 
The health plan's determination is upheld. 

The patient is a male with vitiligo and a pruritic chemotherapy drug-induced rash since completing chemotherapy for Non-Small Cell Lung Cancer (NSCLC). The patient has been alternating with Opzelura and Mometasone. The vitiligo is on the patient's face and is likely segment (V3) on the right mandible and chin.

The Laser Treatment for Inflammatory Skin Disease is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line topical therapies such as either more potent topical steroids and tacrolimus, or to first-line broadly-focused Narrowband ultraviolet B (UVB) light therapy. Particularly for a patient with a limited history of topical and phototherapy for vitiligo previously utilized, these preferred agents are as appropriate for the treatment of this patient's clinical scenario.
Modern dermatology literature supports use of the health plan-covered and preferred topical medications and broadly-focused Narrowband UVB phototherapy as similarly efficacious to the requested Excimer Laser therapy, particularly for a patient with a limited history of topical and light therapy for vitiligo (and the patient's pruritus) previously utilized, and this literature recommends use of these preferred treatments as appropriate for this patient's clinical scenario.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Type 2 Diabetes.
Treatment:  Mounjaro (tirzepatide).

The insurer denied coverage for Mounjaro (tirzepatide).  The denial is upheld. 

This is an adult male diagnosed with Type 2 Diabetes. This request is for Mounjaro. As per letter, he tried and failed Ozempic, due to side effects (nausea and rash), Trulicity and Victoza. 

The formulary alternatives are not likely to cause the patient an adverse reaction. 

The patient is reported to have failed all three formulary alternatives; however, there are no medical records to support this. The formulary alternatives, therefore, have not been ineffective. 

The requested drug would not be more effective than the formulary alternatives. 

The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes.  It has been shown in clinical trials to lead to improvement in hemoglobin A1c (glycated hemoglobin) as well as weight loss (1-3).

There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American diabetes Association guidelines recommend using glucagon like peptide 1 (GLP-1) receptor agonists as a first line agent. There is no preference for the requested medication over GLP-1 receptor agonists(4). The patient can try the formulary alternatives.  

The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.

The formulary drugs are not expected to cause adverse effects.

The formulary drugs were tried, but there is no documentation /clinical records provided showing an adverse reaction or contraindication.

The formulary drugs are 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 Mounjaro (tirzepatide) is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Asthma
Treatment: Atrovent HFA
The insurer denied Atrovent HFA
The determination is overturned.

This is a female patient with a diagnosis of moderate persistent asthma who is currently on Breo Ellipta, Spiriva Respimat and Atrovent Hydrofluoroalkane (HFA). The provider is requesting continued Atrovent HFA for treatment of the patient's asthma. The patient has been well controlled with Atrovent HFA. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.
The formulary drugs will not be as effective as the non-formulary drug.
Per the clinical information provided, the patient has a diagnosis of moderate persistent asthma and is currently on Breo Ellipta, Spiriva Respimat and Atrovent HFA. The provider is requesting continued Atrovent HFA for treatment of the patient's asthma. The patient had an adverse reaction to Albuterol (rash & dyspnea). While the patient is away from home, nebulized medications, such as the formulary alternative of ipratropium nebulized, are prohibitive. In order to adequately treat the patient's any symptoms while out of the house the provider is requesting continuing the Atrovent HFA inhaler. The other formulary alternatives: Yupelri and Spiriva are long-acting medications and not indicated for the relief of acute symptoms (reliever inhaler). Also, the patient is already on Spiriva Respimat. In addition, the patient has been well controlled with Atrovent HFA.
There are studies that show that maintaining medication in the treatment of asthma has positive outcome and changing medications may be detrimental to asthma control. Bjermer in his editorial in Respiration states "Switching may be associated with a poor inhalation technique, reduced disease control and quality of life, increased use of other treatments and health care resources, and a greater chance of unsuccessful treatment...It is recommended that patients with stable disease remain on their current device." In addition, the patient is currently stabilized on the requested medication and a change in therapy may cause a potential destabilization of her asthma control and/or require extensive management and resources that have been previously utilized. The Atrovent is needed to prevent an illness (asthma exacerbations) and prevent endanger this patient's life, is being given at the right places and at the right levels of care for the treatment of members' health conditions, is consistent with health care practice guidelines and standards that are endorsed by professional health care or government agencies, is consistent with the diagnosis of the conditions, it is not more intrusive or restrictive than needed to give a good balance of safety, effectiveness and efficiency.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overweight.
Treatment: Wegovy.
The health plan denied: Wegovy.
The determination is Upheld.

The patient is a male diagnosed with obesity. This request is for Wegovy. As per a letter from his treating physician, he is obese with a body mass index (BMI) of 28.19, and his weight was 205 pounds (lbs). He has tried exercise and diet. He is taking phentermine 37.5 milligrams (mg) to lose weight with very little success. As per a recent visit note, his weight has fluctuated at 183 lbs, 175 lbs, and 178 lbs, all on phentermine.
At issue is the medical necessity of Wegovy.
The health plan's determination of medical necessity is upheld.
The requested health treatment of Wegovy is not medically necessary for this patient.
Semaglutide is a Glucagon-like Peptide1 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 the 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.
The standard of care based on multiple societal guidelines [8-13] 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 28.19 with no documentation of a weight-related comorbidity. The request does not meet the standard of care and is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Immunologic 
Home health care

Diagnosis: Psoriasis
Treatment: Home health care
The insurer denied Personal Care Aide: 42 Hours per Week, Consumer Direct, 1 Client. 
The health plan's determination is overturned. 

The patient is a male with past medical history of cerebral venous thrombosis, anxiety, gastroesophageal reflux disease (GERD), psoriasis, asthma, and hypertension (HTN) who had 14 hours of personal care aide (PCA) services.

Personal Care Aide: 42 Hours per Week, Consumer Direct, 1 Client is medically necessary for this patient.
The patient's medical provider documented medical necessity of increased PCA hours. There is documentation of the patient's chronic medical condition, psoriasis and psoriatic arthritis, which causes pain, itching, and swelling. The medical provider's letter documented assistance needs with multiple activities of daily living (ADL) and Instrumental activities of daily living (IADL) including getting dressed, sitting down, getting up, cleaning, cooking, laundry, medication administration, shopping, taking out the garbage, getting to appointments, and running errands. The assessment performed underestimated the patient's care needs. There was documentation in the medical record being the patient could barely walk and was in a lot of pain. In addition, there are telephone notes documenting the patient's difficulty in obtaining the proper treatment for his chronic illness due to multiple allergies to multiple therapies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The requested increase in PCA hours is not solely for adult supervision or companionship but to assist the patient with ADLs and IADLs. 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, the requested services 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 his own home.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chronic hypoxic respiratory failure secondary 
to pulmonary fibrosis, moderate to severe dementia, major depression, hypertension, hyperlipidemia, benign prostatic hypertrophy (BPH) with incontinence, osteoporosis, and diabetes mellitus with difficulty walking
Treatment: Consumer Directed Personal Aid Service (CDPAS), 7 days x 24 hours Per day, split shift, A Total of 168 hours per week
The insurer denied Consumer Directed Personal Aid Service (CDPAS), 7 days x 24 hours Per day, split shift, A Total of 168 hours per week.
The denial is partially approved.

The requested health service is medically necessary, in part.
Specifically, increase to live-in services as opposed to split-shift is medically necessary.

The patient needs assistance with all activities of daily living due to overall all decline. He lives with his son who works long hours and is unable to assist. However, there is no indication that the patient's needs would prevent the aide from getting five hours of consecutive sleep. Therefore, an increase to live-in is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient had a history of recurrent diverticulitis and presented with abdominal pain. The patient went to a different emergency room (ER) and was diagnosed with diverticulitis and an adjacent phlegmon but no free air or abscess. The patient was afebrile and the vital signs were stable. There were no peritoneal signs. Intravenous (IV) antibiotics were started and by the next day the patient was much improved. The patient's diet was advanced and the patient was discharged on an oral antibiotic. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-150 for Acute Diverticulitis. Clinical indications for admission include hemodynamic instability, peritoneal signs, persistent gross bleeding, or a significant abnormality found on an imaging study. This abnormality can be a fistula, obstruction, or a free perforation. The patient did not have these conditions. The patient also did not require a drainage procedure, have bacteremia, severe vomiting, or an inability to maintain oral hydration after observation care. 

This patient presented with diverticulitis. There was no obstruction, perforation, or need for a drainage procedure. The patient responded rapidly to the antibiotics. The patient could have been started on IV antibiotics with observation care and then been discharged on oral antibiotics. The patient did not meet MCG criteria for admission for Acute Diverticulitis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission 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 full hospital admission is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Aspirin Exacerbated Respiratory Disease (AERD); Nasal Polyps. 
Treatment: Xhance Nasal (fluticasone propionate). 
The insurer denied Xhance Nasal (fluticasone propionate). 
The health plan's determination is overturned. 

This is a female patient with a diagnosis of Aspirin Exacerbated Respiratory Disease (AERD); Nasal Polyps. 

A formulary exception is indicated in this case. The formulary drugs will be less effective than the requested non-formulary drugs. The adverse effects are comparable. 

Xhance is Food and Drug Administration (FDA) approved for the treatment of nasal polyps in patients 18 years of age or older. This approval was based on the results of 2 pivotal randomized, double-blind, dose-ranging clinical trials in adults 18 years and older with nasal polyps and associated moderate to severe nasal congestion. Efficacy was demonstrated for both tested doses of Xhance. 

The patient has been taking aspirin after desensitization. She is also on Zileuton, Symbicort, Fasenra, and Xhance. The patient has had two sinus surgeries for nasal polyps. She has had regrowth of nasal polyps. She has tried different steroid nasal spray in the past without benefit. The patient meets the FDA-approved indication for the use of Xhance. The Medical literature does not suggest a requirement that patients trial mometasone, beclometasone, or another steroid nasal spray prior to using Xhance. Xhance uses an Optinose Exhalation Delivery System (EDS) designed to deliver medication high and deep in the nasal passages to regions where nasal polyps originate and sinuses drain and ventilate. Steroid nasal sprays like mometasone or beclometasone does not allow this effective targeted delivery approach.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Low Back Pain

Treatment: Pain injections (64483 x 2)

The insurer denied coverage for pain injections (64483 x 2).

The denial is overturned.

This patient has chronic low back pain.  The patient is morbidly obese with a body mass index (BMI) of 49. The patient has tried Physical Therapy (PT), a Home Exercise Program, ice and heat. The patient is also taking Gabapentin and topical medications. An electromyelogram (EMG)/nerve conduction velocity (NCV) shows bilateral L (lumbar) 5 radiculopathy. The patient's magnetic resonance imaging (MRI) shows scoliosis, degenerative disc disease at L4-L5 and L5-S (sacral) 1, and facet arthropathy. The request is for bilateral transforaminal epidural steroid injections.

Helm et al (1) conducted a systematic review and meta-analysis and found:

" Eleven randomized controlled trials dealt with various aspects of transforaminal injections for radicular pain owing to disc herniation. Based on these studies, there is Level 1 evidence supporting the use of transforaminal injections for radicular pain owing to disc herniation. A meta-analysis showed that at both 3 and 6 months, there was highly statistically significant improvement in both pain and function with both particulate and nonparticulate steroids."
 
Manchikanti et al (2) published evidence-based guidelines and found:

"Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness."

The requested injections are 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 pain injections (64483 x 2) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic low back pain

Treatment: current procedural terminology (CPT) codes L8680 and L8688 - ReActiv8 Restorative Neuromodulation System - (peripheral nerve stimulator)

The insurer denied coverage for current procedural terminology (CPT) codes L8680 and L8688 - ReActiv8 Restorative Neuromodulation System - (peripheral nerve stimulator)

The denial is upheld
 

This woman has chronic low back pain and pelvic pain. She has had Physical therapy and is not considered a surgical candidate. She has had non steroidal anti-inflammatory drugs (NSAIDs) and had prior radiofrequency ablation (RFA) of her lumbar facet joint innervation.  The request is for Reavtiv8 placement.

There are no studies comparing ReActiv8 with an active comparator.

Several serious adverse events were reported, and mild and moderate adverse events were common, some of which led to need for revision surgery and reimplantation."

Further, another clinical trial is underway, NCT04803214, (4) which is to compare this device with optimal medical management and is still recruiting patients.

The efficacy and adverse events of this treatment is still being evaluated.

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 current procedural terminology (CPT) codes L8680 and L8688 - ReActiv8 Restorative Neuromodulation System - (peripheral nerve stimulator) is not substantiated.