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

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (code 
64628 and 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (code 64628 and 64629)
The denial is upheld.

The patient is an adult female with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as being experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, and RFA (radiofrequency ablation). MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. She has failed previous lumbar spine surgery. 

The health plan should not cover the requested health service.

The patient is an adult female with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as being experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, and RFA (radiofrequency ablation). MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. She has failed previous lumbar spine surgery.
The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It has been shown effective in RCT (randomized controlled trials) with 5-year results. 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.

However, the patient is not documented to have failed or attempted sacroiliac joint injections, which are common causes of axial low back pain. In addition, there is no documentation of failed medications, which is a component to conservative treatment. 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 the alternatives sacroiliac injections do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Pharmacy/Prescription Drug

Diagnosis: Crohn's disease
Treatment: Stelara 90 mg/ml syringe (every 6 weeks) 
The insurer denied Stelara 90 mg/ml syringe (every 6 weeks).
The determination is upheld.

This is a male patient with a history of Crohn's disease. He has tried and failed Humira. He was started on Stelara and received the first dose (intravenous infusion). His drug level was measured and was 22. The requested service is Stelara at 90 milligrams (mg) every 6 weeks. At issue is the medical necessity of the requested Stelara.

Stelara at 90 mg every 6 weeks is not medically necessary.
Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease (CD) and ulcerative colitis in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with inflammatory bowel disease.
However, this patient has only received the initial intravenous dose and has not been established on the standard dosing regimen (90 mg every 8 weeks). The records do not show that the patient has tried and failed the standard dosing regimen. The measured drug level is adequate as the recommended range in the literature is greater than (&gt;) 4.5 (10).
Therefore, continuation of Stelara is appropriate, but at the standard dose (90 mg every 8 weeks). The requested dosing regimen is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes.
Treatment: Mounjaro.
The health plan denied: Mounjaro.
The determination is: Upheld.

The patient is a female diagnosed with type 2 diabetes mellitus (DM) with hyperglycemia. She has a history of hypertension (HTN) and hyperlipidemia (HLD). She is status/post (s/p) gastric bypass 14 years ago. As per the letter attached, she tried and failed Victoza and Ozempic. She is on Metformin, Jardiance, and Ozempic 1 milligram (mg) weekly according to the note. The patient also previously tried Byetta. Her hemoglobin A1C (HbA1C) has ranged from 6.9 percent (%) to 7.4% over the past 4 years. Her provider has prescribed her Mounjaro for the treatment of her type 2 DM.
At issue is whether Mounjaro, a non-formulary drug, will be more effective and have less adverse effects than the formulary drugs.
The health plan's determination is upheld in whole.
The formulary drugs will not be or have not been ineffective as the non-formulary drug (Mounjaro), or have adverse effects. The formulary alternatives are Ozempic, Rybelsus, Trulicity, and Victoza.
The requested medication Mounjaro (Tirzepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 DM. It is a glucagon-like peptide 1 (GLP-1) and gastric inhibitory peptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in HbA1C, 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 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 is reported to have tried Ozempic and Victoza. The patient has not tried Rybelsus or Trulicity. The patient's most recent HbA1C was almost at goal at 7.1%. The patient has not failed Ozempic, as the patient's highest Ozempic dose was 1 mg, and the patient can use 2mg.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism
Treatment: 18 speech therapy visits
The insurer denied coverage for 18 speech therapy visits
The denial is upheld 

The patient is a minor with a diagnosis of autistic disorder and developmental disorder of speech. According to the Visit Note Report, the child "exhibits significant developmental and cognitive delays, poor language and communication skills, and features of autistic spectrum disorder. The patient has a limited ability to communicate verbally and uses gestures and points to objects. The patient has sensory issues and is sensitive to loud noises." Under review is the medical necessity of 18 home speech therapy visits. 

The clinical records do not support the medical necessity of the requested 18 speech therapy home visits; particularly since the patient is receiving speech therapy services at school 2 days per week. The speech therapy notes are handwritten, poorly legible and do not document what specific speech therapy services were provided at home and cannot be appropriately and safely provided by the therapist(s) at school. In addition, speech therapy treatment has been provided for well over a year, with limited documented quantitative improvement or updated attainment of specific treatment goals. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. 

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the 18 speech therapy visits are 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 18 speech therapy visits is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This elderly female patient presented with left lower quadrant pain and nausea for one day. Vital signs were stable; her temperature was 100.4. The patient's exam showed left lower quadrant tenderness. Pertinent labs included a white blood cell (WBC) of 14.3. Her chest x-ray showed no acute disease. The computed tomography of the abdominal/pelvis showed diverticulitis. The patient was admitted with diverticulitis. Plan of care included intravenous and oral antibiotics. 
On day #1, the patient's vital signs were stable, and she was afebrile. The patient was feeling better. Her white blood cells (WBCs) were 8.8. The plan was to transition to oral antibiotics when discharged per Infectious Disease consult. On day #2, the plan was to advance from a clear to full liquid diet. On day #3, the patient was continued on the current management. 
The patient was discharged the next day.

The proposed treatment was not medically necessary.

This patient was admitted with diverticulitis. The health plan denied coverage because treatment in the emergency room would have been sufficient. The patient was hemodynamically stable. She had a low-grade fever. Labs were remarkable for mild leukocytosis. She did not have uncontrolled pain. She did not have persistent vomiting. She was able to tolerate oral intake. The patient was treated with both oral and intravenous antibiotics but was cleared to transfer to oral antibiotics if discharged. The patient had not failed an observation level of care. Acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Left hip osteoarthritis
Treatment: Outpatient Surgery (20985 x1, 27160 x 1)
The insurer denied coverage for Outpatient Surgery (20985 x1, 27160 x 1)
The denial is modified 

According to the documentation submitted, this is a patient with a history of left hip osteoarthritis, chronic pain, post-traumatic stress disorder, anxiety and asthma. The patient had a physician's office visit for left hip pain. The note stated that the patient had less than a 10-minute standing and walking tolerance and had to utilize a cane to assist with ambulation. The patient had previously undergone hip arthroscopy which failed at giving the patient pain relief. At that time the patient was found to have significant osteoarthritis. The patient noted no improvement and still had significant limitations as a result of the left hip pain. 

The insurer has denied coverage for Outpatient Surgery (20985 x1, 27160 x 1) as not medically necessary. In their Final Adverse Determination letter they write that the patient asked for a total left hip replacement, to approve this service, the following criteria must be met: criteria from the turning point guidelines named "Total Hip Replacement (OR-1001)", "computer assisted navigation (OR-1035), and "Medical record documentation (GN-1002)". Based on the information provided, these criteria are not met.

The medical records were consistent to confirm a pain generator. There is presence of pathology localized to the left hip joint. Subjective complaints and objective findings confirm the progressive deterioration to her hip joint. Imaging studies using magnetic resonance imaging (MRI) and X ray show joint pathology. The patient has received several treatments which were not effective; that is, arthroscopy, medications and physical therapy. The records showed she attempted but could not tolerate the service. She had also undergone bariatric surgery. She was counseled by her physician about additional weight loss. She was counseled and reported not smoking. 

The use of the computer navigation (20985 X1) in performing the operation is not essential. Placement of components are improved but no evidence for long term outcome has been reported. 

In conclusion, the total hip replacement (27160 X1) would be necessary. The use of computer navigation would not.

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The denial of the computer navigation (20985 X1) is upheld. The medical necessity for Outpatient Surgery (27160 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological/Gynecological/Pelvic and Perineal Pain
Treatment: Radiology Services/Computed tomography (CT) of the abdomen and pelvis with contrast 
The health plan denied the requested computed tomography (CT) of the abdomen and pelvis with contrast as not medically necessary. The health plan's determination is upheld.

This is a female patient with a stated diagnosis of pelvic congestion syndrome (by history) who presented with pelvic heaviness and a variety of urinary symptoms. A computed tomography (CT) venogram of the abdomen and pelvis performed was interpreted as normal, with normal pelvis venous vasculature.
At issue is the medical necessity for the requested CT of the abdomen and pelvis with contrast.

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

No. The patient does not satisfy plan criteria for the CT scan of the abdomen and pelvis with contrast to be considered medically necessary. There has not been an initial pelvic ultrasound performed to investigate the unexplained pelvic pain and/or dyspareunia. There has also not been any appropriate urological workup for the patient's urinary symptoms. Plan criteria is based upon peer-reviewed literature and accepted standards of medical practice. The CT scan of the abdomen/pelvis with contrast is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart failure, COVID (Coronavirus disease)
Treatment: Personal Care Worker (PCW) services 12 hours/day 7 days/week
The insurer denied PCW services 12 hours/day 7 days/week.
The denial is upheld.

This elderly male patient has a history of hypertension, heart failure, thrombocythemia, and COVID (Coronavirus disease) pneumonia. He was hospitalized last year after being admitted with syncope due to hypoxia. The denial of personal care worker (PCW) services, 12 hours/day, 7 days/week, is being appealed. The health plan approved 8 hours/day, 7 days/week. Uniform Assessment System (UAS) evaluation performed 8 months ago shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with lower body dressing; limited assistance with managing finances and medications, bathing, personal hygiene, upper body dressing, walking, locomotion, and toileting; and independent with bed mobility and eating.

A letter from the patient reports that he has prolonged effects after being infected with COVID. Lack of oxygen results in loss of consciousness. A letter from the provider notes the patient has chronic medical conditions. The patient suffers from syncope, shortness of breath, and unsteady gait. His condition is deteriorating due to unsteady gait. He has a history of multiple falls.

The proposed treatment is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs), health maintenance activities, and routine support services. This patient has multiple chronic conditions, including recent COVID pneumonia. The denial of PCW services 12 hours/day, 7 days/week, is being appealed. The health plan approved 8 hours/day, 7 days/week. UAS evaluation performed 8 months ago, shows the patient needs assistance with all ADLs except bed mobility and eating. Appeal statements indicate that the patient is oxygen dependent. He has syncope related to hypoxia. He has a history of falls due to an unsteady gait. The information provided does not support that the patient has functional needs that require an increase in PCW hours. PCW is not indicated for supervision or when no tasks are being performed. The approved PCW is appropriate to meet this patient's needs for assistance with ADLs. The proposed increase to services 12 hours/day, 7 days/week, is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute stroke
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who presented to the emergency department with disorientation, dysarthria and aphasia. Her National Institute of Health (NIH) stroke scale score was 4. The patient's computed tomography (CT) of the head was negative for acute pathology. Magnetic resonance image (MRI) confirmed acute stroke. The patient was discharged the next day with outpatient therapies.

The proposed treatment was not medically necessary.

There was no reason the patient could not have been managed at a lower level of care. The patient did not have a significant neurological deficit at presentation and National Institute of Health stroke scale (NIHSS) score was only 4. There were no concerning findings on computed tomography (CT) or magnetic resonance image (MRI) that required acute inpatient level of care (Mendelson and Prabhakaran, 2018). The patient was not treated with thrombolytic agents or mechanical thrombectomy. She was hemodynamically stable and did not have any detected cardiac arrhythmia to warrant acute inpatient level of care. She did not require acute anticoagulation or invasive procedure to warrant acute inpatient care (Campbell et al., 2019). Taken together, she could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a man who presented to the emergency department (ED) with right sided abdominal pain of 2-days duration. He has a history of hyperlipidemia. At the time of presentation, the patient was without fever and the heart rate was 66. He had a tender right upper abdomen per the examination. The white blood cell (WBC) count was elevated at 17.5. The complete metabolic panel showed normal bilirubin and normal transaminases. An abdominal ultrasound showed gallstones and a thickened gallbladder. 

The inpatient level of hospital care was not medically necessary. An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with abdominal pain. The records and the diagnostic work up supported the diagnosis of cholelithiasis/cholecystitis, and this diagnosis was established. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED assessment, surgical consultation, monitoring, provision of antibiotics and fluid, surgical treatment, and overnight care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign prostatic hypertrophy
Treatment: Computed Tomography Angiography (CTA)
The health plan denied Computed Tomography Angiography (CTA). The denial is upheld.

The patient is an adult male with benign prostatic hypertrophy (BPH). The request is for a pelvic CTA (Computed Tomographic Angiography).

The peer-reviewed medical literature does not support obtaining a pelvic CTA (Computed Tomographic Angiography) prior to a prostate artery embolization. As such, the request is not consistent with the standard of care.

Therefore, given the above, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

This is a female patient with a Class I malocclusion and anterior crossbite of tooth number (#) 7. Tooth #27 is showing moderate recession. She is treatment planned for orthodontics to correct her malocclusion. At issue is the medical necessity of braces and monthly visits.

This patient presented with an anterior crossbite and significant 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 significant mandibular anterior crowding. Additionally, tooth #7 is in crossbite. This tooth has a high risk for restorative problems in the future due to the 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. Tooth #27 already has moderate recession, and further movement of #27 will likely lead to the need for future for periodontal grafting on this tooth. 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: Kidney stone.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
This is an adult with no significant past medical history who presented to emergency department (ED) complaining of left flank pain. Patient was afebrile with stable vitals, left Costovertebral angle tenderness (CVAT) on examination. White blood cell 6000, lactate 2.14, urinalysis - positive blood, positive protein, positive white blood cell. Computed tomography (CT) scan revealed a 5 millimeter (mm) obstructing calculus in left mid ureter with moderate left hydroureteronephrosis. Patient given intravenous (IV) fluid bolus, intravenous morphine/Zofran/ Toradol, then repeated IV bolus saline and 4 milligrams (mg) morphine intravenously. Patient was admitted to medicine for intractable pain due to a renal calculus. Patient improved after admission, labs stabilized, patient stable for discharge 3/6 with outpatient urology follow up but failed to pass any stones. 

Per Milliman Care Guidelines (MCG) Health (26th) Real Colic and Kidney stones; patient fails to meet clinical indications for admission to inpatient care. These include hemodynamic instability, acute renal failure, bilateral obstruction, urinary tract infection, severe pain requiring acute inpatient management. Patient did not have any of these clinical situations.

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.