Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Diabetes mellitus type 2
Treatment: Formulary exception for Mounjaro
The insurer denied: Formulary exception for Mounjaro
The denial is Overturned.

The patient is an adult female with type 2 diabetes treated with metformin, Trulicity 3 mg (milligrams) weekly, and Basaglar 34 units at bedtime. The request for Mounjaro is under review. 
The patient's A1C (glycated hemoglobin) is 5.6% (percent). The prior request was denied coverage by the health plan, as approval on criteria requires trial and failure, intolerance, or contraindication to three or more of the following: Ozempic, Rybelsus, Trulicity, and Victoza. The denial is being appealed.

The health plan should cover the Formulary exception for Mounjaro.

This request is for Mounjaro for the treatment of type 2 diabetes. The prior request was denied coverage by the health plan, as the patient has not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. This patient has tried Trulicity. Mounjaro has been shown to be superior to Ozempic [1]. The mean change from baseline in the glycated hemoglobin level was 2.01 percentage points, 2.24 percentage points, and 2.30 percentage points with 5 mg (milligrams), 10 mg (milligrams), and 15 mg (milligrams) of Mounjaro, respectively, and 1.86 percentage points with Ozempic; the estimated differences between the 5-mg (milligrams), 10-mg (milligrams), and 15-mg (milligrams) Mounjaro groups and the Ozempic group were 0.15 percentage points (95% confidence interval [CI], 0.28 to 0.03; P=0.02), 0.39 percentage points (95% CI [confidence interval], 0.51 to 0.26; P< [less than]0.001), and 0.45 percentage points (95% CI [confidence interval], 0.57 to 0.32; P<0.001), respectively. Rybelsus and Victoza have been shown to be inferior glucose lowering agents as compared to Ozempic, and Ozempic is inferior to Mounjaro.
This patient, who is on insulin therapy, requires Mounjaro, given its greater effectiveness for lowering glucose. This may permit the patient to stop insulin therapy. The formulary alternatives are not appropriate, as they do not have the same robust glucose lowering effect. Without Mounjaro, this patient will be at increased risk of the complications of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the health plan should cover the formulary exception for Mounjaro.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  End stage renal disease.
Treatment:  Personal Care Aide (PCA) Services 24 Hours (split shift) Per Day, 7 Days Per Week.

The insurer denied Personal Care Aide (PCA) Services 24 Hours (split shift) Per Day, 7 Days Per Week.  The denial is overturned.

This elderly female has end stage renal disease, hypertension, hyperlipidemia, angina, neuropathy, and anemia. She is receiving hospice care. Denial of personal care aide (PCA) services 24 hours (split shift) per day, 7 days per week is being appealed. The plan approved personal care aide (PCA) live-in services, 7 days per week. A letter from visiting nurse service notes the member is unable to transfer alone, is incontinent of bowel and bladder and requires total care with all activities of daily living (ADLs). She requires turning every 2 hours and nighttime repositioning. Visit notes have been provided to support this information.

The proposed treatment is medically necessary.

Personal care services are necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide 5 hours daily of uninterrupted sleep during the aide's shift. This member has multiple chronic conditions. She is in hospice care due to end stage renal disease. Denial of personal care aide (PCA) services 24 hours (split shift) per day, 7 days per week is being appealed. The plan approved personal care aide (PCA) live-in services, 7 days per week. The health plan denied the increase in hours because additional care is not indicated for supervision. The member has durable medical equipment (DME), include a rotating air mattress. A statement from her provider notes that the member requires total assistance with activities of daily living (ADLs), as well as turning and repositioning every 2 hours. She is incontinent of bowel and bladder. Office visits notes support this reported level of functioning. The appeal statements support that the member is dependent with all activities of daily living (ADLs) and requires frequent assistance with toileting, transfers, and turning/repositioning. This member has continuous needs that will not give the aide 5 hours daily of uninterrupted sleep during the aide's shift. The approved personal care aide (PCA) live-in services, 7 days per week are insufficient to meet this member's needs. The proposed personal care aide (PCA) services 24 hours (split shift) per day, 7 days per week are medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: chronic pain
Treatment: Peripheral Nerve Stimulator
The insurer denied Peripheral Nerve Stimulator. The health plan's determination is upheld. 

The patient is a male with chronic pain. He has neck pain. There is also lumbar radicular pain. He has a history of L5-S1 [lumbar 5 - sacral 1 vertebrae] fusion and cervical fusion. He has had local injections. There is a request for cervical Peripheral Nerve Stimulator. 

The requested peripheral nerve stimulator is not medically necessary. Peripheral nerve stimulation involves placing a small electrical device (a wire-like electrode) next to one of the peripheral nerves. These are the nerves that are located beyond the brain or spinal cord. The electrode delivers rapid electrical pulses that are felt like mild tingles/paresthesias. This modality is not recommended until there is higher quality research, including research on adverse events. The supporting evidence is limited to case reports, retrospective reviews, and small case series, mostly focusing on migraine treatment. Given the lack of support in the medical literature, the requested peripheral nerve stimulator is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic pain
Treatment: Peripheral Nerve Stimulator
The insurer denied Peripheral Nerve Stimulator. 

The health plan's determination is upheld. 

The patient is a male with chronic pain. He has neck pain. There is also lumbar radicular pain. He has a history of L5-S1 fusion and cervical fusion. He has had local injections. There is a request for cervical Peripheral Nerve Stimulator. 

The requested peripheral nerve stimulator is not medically necessary. Peripheral nerve stimulation involves placing a small electrical device (a wire-like electrode) next to one of the peripheral nerves. These are the nerves that are located beyond the brain or spinal cord. The electrode delivers rapid electrical pulses that are felt like mild tingles/paresthesias. This modality is not recommended until there is higher quality research, including research on adverse events. The supporting evidence is limited to case reports, retrospective reviews, and small case series, mostly focusing on migraine treatment. Given the lack of support in the medical literature, the requested peripheral nerve stimulator is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myocardial infarction
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned
 
This is the case of an adult patient that presented to the hospital complaining of chest pain and dyspnea on exertion and at rest.  She has a complex past medical history that included ischemic heart disease and coronary artery bypass graft (CABG) with a preserved left ventricle ejection fraction (LVEF) (50-55%), peripheral vascular disease with osteomyelitis, diabetes, hypertension and end stage renal disease (ESRD) on dialysis. In addition to chest pain, the patient noted brown vaginal discharge. On arrival to the hospital vital signs were stable. Physical exam revealed previous distal extremity toe amputations. 12 lead electrocardiogram (EKG) revealed sinus bradycardia without ischemic ST or T wave abnormalities. Serum blood testing revealed a high sensitivity troponin level of 49 and an elevated Pro B type natriuretic peptide (3366).  The patient was admitted to the hospital for monitoring and treatment.  Echocardiogram revealed a preserved LVEF and moderate to severe aortic stenosis. The patient was treated with medical therapy for myocardial infarction and released.

This patient presented with chest pain and an elevated troponin level. Her HEART (History, EKG, Age, Risk factors, and troponin) score put her in a high-risk category, consistent with a high risk of future cardiac events. (Reference 1, 2) She was admitted and ultimately noted to have a new moderate to severe aortic stenosis.  Based on the high-risk score using both the HEART and TIMI 9 (thrombolysis in myocardial infarction) risk stratification, admission for observation and work up was medically necessary. Risk assessment of patients presenting with chest pain and ST changes on EKG as well as negative cardiac enzymes was performed by Sanchis et al. (Reference 3) Using their risk stratification schema, this patient would have a high risk of future myocardial infarction or death within one year. In conclusion, acute care hospital admission was medically necessary.

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

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

Based on the records, this inpatient admission was not justified as this patient could have been managed as noted by the insurer in an ambulatory/observation setting. The patient had an uneventful laparoscopic (lap) cholecystectomy for cholelithiasis. The patient did not have acute cholangitis. The patient did not have a significantly elevated white blood cell count and did not have a fever. The patient did not have elevated liver function tests. The patient did merit having the gallbladder taken out as the patient had biliary dyskinesia and a history of biliary colic. 

This patient did not need to be admitted as the patient could have been managed with an outpatient/observation basis. The patient did not have any indication for acute inpatient admission. The patient was seen in the Emergency Department (ED) and surgery was not performed until day 2 of admission. The patient had an uneventful lap cholecystectomy, and the patient was discharged the following day. The patient did not need an acute inpatient admission. The patient should have been cared for in an ambulatory observation setting. Furthermore, according to MCG (Milliman Care Guidelines) Inpatient and Surgical Care 27th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory. This patient should have been managed without an inpatient acute admission for this procedure. MCG also noted that analysis of a cohort of 95,523 adult patients who underwent laparoscopic cholecystectomy within 10 days of presentation with acute cholecystitis found that 65% of the laparoscopic cholecystectomies were performed either the day of presentation (day 0) or the following day (day 1). Ambulatory status would have been appropriate. The patient was discharged within 23 hours following the lap cholecystectomy.

MCG General recovery care 27th edition Ambulatory surgery exception criteria notes that ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. Given the above the patient did not warrant inpatient status and could have been managed in an ambulatory setting/observation setting. The procedure did not occur until the second day of admission. The surgery could have happened sooner, and the patient did not warrant inpatient admission for this. It was not a complex surgical situation and was not a high anesthetic risk.

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:  Nasal Polyps.
Treatment:  Xhance 93 (micrograms) MCG/ACT NA EXHU (actualized solution in sodium for aerosol spray).

The insurer denied coverage for Xhance 93 MCG/ACT NA EXHU.  The denial is upheld.

Per the documentation submitted, it is stated that the patient has used several nasal steroid sprays to the point where the nasal septum was beginning to atrophy. There is a history of sinus surgery/polypectomy and multiple courses of antibiotics and steroids by mouth. The patient has anosmia (inability to sense odor). No polyps were noted on physical examination. Xhance and desloratadine were ordered. Labs for RAST (Radioallergosorbent test) and IgE (Immunoglobulin E) levels were ordered. A denial by the insurer was issued for Xhance stating that the patient has not had an adequate 12-week trial with both preferred agents at an optimized dose and claim records show filling fluticasone nasal spray on at least 3 occasions. An appeal was signed but not dated by the physician assistant. Another denial letter by Fidelis was sent related to a medical necessity denial for Xhance. The printed guidelines for Xhance approval were not provided but the global prescription criteria were referenced, "not taken or had a poor response to medications on the preferred list" (fluticasone and budesonide). It does not state that both medications must have been failed or that 2 medications had to be used simultaneously.

The patient has met the criteria of failing at least 1 formulary nasal steroid spray, but currently the patient has not been shown to have nasal polyps (on examination, endoscopy or radiology), which is the indication for Xhance. The reviewer therefore upholds the denial based on inadequate documentation of medical necessity.

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 Xhance 93 (micrograms) MCG/ACT NA EXHU is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Axillary Swelling and Rhinorrhea (s/p incision and drainage)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is a pre-school known autistic child with known fever for 24 hours, nasal congestion, clear nasal discharge and a noted enlarging left axillary growth. The growth was noted to have a pimple in the middle. The patient presented to an emergency department with a swelling in the left axilla and fever with nasal congestion and discharge. The patient was admitted for an incision and drainage as well as antibiotics. The patient was found to have a MRSA (methicillin-resistant staphylococcus aureus) infection that was treated appropriately with antibiotics and the patient was placed on an appropriate oral antibiotic when the patient was afebrile and hemodynamically stable for discharge.

The treatment is medically necessary. 

The patient was noted to have a large axillary abscess. Upon assessment, it required incision and drainage to appropriately access the depth of the infection and to treat an underlying dermatological infection, the source of the infection must be found and removed, as well as placing the patient on antibiotics. As such, the patient required inpatient care to appropriately sedate the patient so the procedure can be done. The patient has a known autism spectrum diagnosis, which requires social and behavioral support provided. The patient required follow up of the discharge found to assess if it was responsive to the initial antibiotic and to ensure that the patient's abscess was appropriately opened and surgically treated. These needs as well as the assessment of the patient's clinical condition, required an inpatient stay to treat the infection due to the unknown duration of the pathology as well as the depth of the disease. Patients with autism spectrum disorder are not always able to be assessed appropriately for clinical symptoms. 
The treatment is medically necessary to ensure that the infection is removed from its source and that the antibiotics used are appropriate for this patient's pathology.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intraosseous basivertebral nerve ablation
The health plan denied the Intraosseous basivertebral nerve ablation
The health plan's determination is upheld.

The patient is a female with a history of longstanding lower back pain. She has had the following treatments: home exercise program (HEP), lumbar epidural steroid injections (LESI) (no durable benefit), physical therapy (PT) and medications (Acetaminophen, Cyclobenzaprine, Hydrocodone and nonsteroidal anti-inflammatory agents (NSAIDS) ). Her magnetic resonance imaging (MRI) showed mild spondylosis and an annular tear at (lumbar) L3-4. Her treating physician has ordered the Intracept procedure. Pain is 5-8/10. She also had prior evaluation with Rheumatology and Neurology. She was diagnosed with small fiber peripheral neuropathy. I looked for and could not find a recent thorough spine examination including provocative maneuvers to support vertebrogenic pain.

At issue is whether the proposed health service or treatment of an Intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

I uphold, in whole, the health plan's determination.

At this time, it is unlikely that the proposed health service will be more beneficial than standard treatment. Her notes indicate most recently PT had provided some benefit. I looked for and could not find detailed PT notes. I also looked for and could not find a recent spine examination to support vertebrogenic pain. I also looked for and could not find evidence of a recent MRI demonstrating Modic I or II changes of the lumbosacral spine. While this procedure may be a reasonable option in the future for this patient, at this time, there is not enough evidence to support that it may be more beneficial than a standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intraosseous basivertebral nerve ablation
The health plan denied the Intraosseous basivertebral nerve ablation
The health plan's determination is upheld.

The patient is a female with complaints of low back pain. Pain has been present for many years. Prior treatment has included activity modification, home exercises, lower back injections, medications, as well as physical therapy. The patient has trialed medical marijuana as well as opioids. The pain impacts her activities of daily living (ADL). Pain ranges from 5-8 out of 10. A magnetic resonance imaging (MRI) of the lumbar spine showed degenerative changes at the (lumbar) L4 and L5 vertebral bodies.
At issue is whether the proposed health service or treatment of an Intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

I uphold, in whole, the health plan's determination.

The proposed health service or treatment of an Intraosseous basivertebral nerve ablation 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.

There is a request for intraosseous basivertebral nerve ablation. 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 proposed health service or treatment of an Intraosseous basivertebral nerve ablation 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: Low back pain
Treatment: Intraosseous basivertebral nerve ablation
The health plan denied the Intraosseous basivertebral nerve ablation 
The health plan's determination is overturned.

This patient has a long history of chronic back pain. She underwent extensive treatments including pain medications, physical therapy (PT) and epidural injections. However, none of these provided her with adequate pain relief. Her level ranges from 5/10 to 8/10. She has decreased quality of life (QOL) and functional status due to chronic back pain. A magnetic resonance imaging (MRI) revealed Modic changes at (lumbar) L4/5 with mild degenerative disc disease and facet arthropathy. Physical exam (PE) was unremarkable with negative straight leg raise (SLR) and facet loading tests.

The issue is whether the proposed health service or treatment of an Intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

I overturn, in whole, the health plan's determination.

Yes. The INTRACEPT system was designed to treat low back pain from the vertebral body by ablating basivertebral nerves. There are multiple clinical trials demonstrating the sustained improvements in pain and function of this intervention for patients with vertebrogenic pain. This patient had failed extensive treatments pain medications, PT and epidural injections. Her pain is severe enough with a negative impact on her QOL and activities of daily living (ADL). Further interventions are medically necessary to improve her 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.